NDA Health Now Donation Request

Name of Requesting Entity/Organization

Name Contact Person:

Position:

Office Phone

Cell

Email

Donation Requested For:

Name of Event/Clinic/Facility:

Shipping Address

City

State/Province

Zip/Postal

Country

Name of Onsite Recipient:

Work Phone

Cell Phone

Requested Delivery Date

Is this program ongoing?

Specific delivery instructions (hours facility is open, inside delivery, elevator access, location of delivery entrance, etc.

Dental products requested (toothbrushes, toothpaste, dental floss, mouthwash)

# of children ages 2-5 yrs.

# of children ages 6-10 yrs.

# of children ages 11+ yrs.

# of Adults

# of Seniors

Donated Clinic Supplies requested*

Select all that appply:

Disposables (tray covers, patient bibs, 2x2 gauze, gloves, gowns, masks)

Restorative materials

Endo supplies

Impression Materials

Hygiene supplies (Prophy angles, prophy paste)

Lab supplies (Stone, plaster)

Sterilization/Disinfection supplies (autoclave bags, hazardous waste bags, disinfectant)

OtherOther

Support materials requested:

Educational brochures

Children’s videos

Adult education presentations (English and Spanish)

Signs/Banners (Digital graphics and design)

OtherOther

IRS non-profit determination letter is required of requesting organization/entity.

Maximum file size: 104.86MB

In exchange for support, the NDA requests acknowledgement of the donation with permission to publish photos and reproduce articles, press releases and/or other statements expressions of appreciation in the NDA Newsletter, Flossline.
NDA will provide the in-kind value of donated products/materials.

NDA HEALTH NOW - Donation Request Form

Subscribe